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Effective Strategies for ACL Injury Rehabilitation for Return to Sport: A Comprehensive Guide

Updated: Jan 15

What is an ACL injury?

Anterior Cruciate Ligament (ACL) injury is a significant injury which can occur often to the knee as a result of . The main purposes of the ACL is to prevent the tibia in moving forwards or rotating inwards, and hence has an important role in maintaining stability of the knee joint. ACL rupture can occur either as a result of a contact or non-contact injury to the knee. Typically, non-contact ACL injuries occur due to change of direction, where the knee moving into hyperextension, collapses inwards (knee valgus) or rotates internally.


How do I know if I have an ACL injury?

ACL injuries typically occur with a specific incident, in which following the knee will develop swelling (effusion) and often a sensation of instability. Occasionally the knee can also experience secondary injury including injury to the meniscus, collateral ligaments (especially the MCL) and underlying cartilage within the knee.


Whilst clinical assessment of the knee has a high degree of accuracy, most undergo an MRI which is the gold standard in diagnosis of this injury.


Do I need surgery for my ACL injury?

Once you've had an ACL injury, it's important to get a supportive team behind you to assist in your decision making. This should include your GP, an Orthopaedic surgeon and physiotherapist. The research in this this space has evolved rapidly over the past 5 years, with new continuing to be published in both the non-surgical and surgical management of these injuries. What is consistent however in the current research base, is that you need to consider your individual circumstances, such as;

  • Whether you have had an isolated ACL injury vs secondary injury to your meniscus or other structures within your knee.

  • Your age.

  • Your goals, particularly if you want to return to sport and to what level of sport you want to return to (such as recreational running vs high level change of direction sport).

  • Your occupation or work requirements.

  • Your home and family situation.

  • If you're playing in professional sport, the timing of the season and contractual considerations.


Some other considerations include;

  • Unfortunately the occurrence of an ACL injury will increase your chance of osteoarthritis into the the future, however it is know that an ACL reconstruction does not modify this risk. You can reduce this risk with a thorough rehabilitation.

  • There is an elevated risk of ACL injury recurrence on both knees even following surgery. Depending on what you read, this can be between 10-25% higher compared to those with no history of ACL injury.

  • Not everyone returns to sport or performance. Whilst a thorough rehabilitation can best improve your chances, it is difficult to predict outcomes outside of the extent of the initial knee injury.

  • There is concern that return to sport without an ACL reconstruction may increase the chance of meniscus or cartilage injury to the knee, particularly in younger athletes.


As such, there is some complexity in the decision making process and hence it is important have a team of people experienced in the management of ACL injuries around you to assist.


How long will it take until I return to sport?

Return to sport following ACL injury has a significant amount of variability between people and can take from 9 months up to 18 months to return to sport. Progression through rehabilitation into returning to sport however is an outcome, not time based process. This means there are criteria which you need to complete in your strength, jumping capacity and training as you progress through sport - this can take different durations between people. Returning to sport based on the time following injury and not your function can lead to a significantly higher chance of reinjury or reduced performance.


Some factors which often contribute include;

  • The extent of the initial injury, and whether there was any coexisting injury (such as meniscus, cartilage or MCL injury).

  • How well the knee is looked after particularly in the first few months (developing recurrent swelling to the knee will often delay your ability to progress).

  • Your work requirements and needing to balance your rehabilitation with this.

  • The function of your knee before surgery. There is evidence which demonstrates going into knee surgery with a settled knee and some level of strength prior will improve your outcomes following surgery.

  • Your age and training history.


How do I reduce my chance of recurrence?

Whilst it is impossible to predict who will or won't have a recurrence, there are measures you can take to reduce your chance of recurrence. This includes;

  • Improving your leg strength and jumping capacity.

  • Develop your cutting and change of direction quality.

  • Improving your landing capacity.

  • Returning to play when you have completed the required strength and jump testing required to play.


What does rehabilitation look like for ACL?



  1. Protection: The initial stages of recovery following ACL reconstruction differs depending on whether you've had an isolated ACL reconstruction or also procedures to other structures in your knee (such as the meniscus or MCL). There is good evidence that a period of rehabilitation prior to surgery will improve outcomes. The main purpose of this is to allow the knee to settle following the injury and regain some strength in the muscles supporting the knee. Within the initial stages of recovery, the primary goals are to reduce the swelling, switch on the quadricep, regain your normal walking pattern and get full extension of your knee. Achieving this will allow your knee to tolerate the main movements required for transitioning into the load introduction phase of your rehabilitation.

  2. Load Introduction: There is generally two phases within the load introduction phase. The first focus of this stage is to reintroduce the primary movement patterns which we will look to load in the strength development stage. This includes the squat, deadlift, lunge, single leg squat and bridge. We will also start to introduce more isolated loading to the muscles which support the knee such as the quadricep, hamstring, calf and glute. Motor learning is an important component of this stage, as this will set you up for the later stages in running and return to sport. Components which are addressed include control of your knee collapsing inwards (knee valgus), foot and ankle control, core and trunk coordination stability and lumbopelvic control.

  3. Strength Development: This stage involves progressively overloading and increasing the intensity of your strength work to regain your normal levels of strength. A key focus of this stage involves building up your jumping and landing capacity to assist in the running, acceleration and change of direction demands in sport. We use professional level equipment including force plates to assess of your jumping capacity.

  4. Return to Performance: This phase is all about piecing everything together to build a plan to return to sport. In the gym, we look to clean up any remaining areas of strength which require further development. Of particular important we look to ensure your jumping and landing capacity is at sufficient levels, as this is often the last physical quality to come back prior to return to sport.


Having a clear plan with outlined goals and criteria to progress in each stage is key to success in rehabilitation. True Active Physiotherapy has significant experiencing in putting together comprehensive rehabilitation and return to play programs together following ACL injury. For enquiries, give us a call at (03) 7503 7657 or you're able to make an appointment online.




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